Review article

Understanding the psychology of geriatric edentulous patients

Ashwin R. Mysore and Meena A. Aras
Department of Prosthodontics, Goa dental college and hospital, Bambolim, Goa, India

doi: 10.1111/j.1741-2358.2011.00496.x Understanding the psychology of geriatric edentulous patients Objective: This article focuses on understanding our older patients who require complete prosthodontic care. By breaking down the patient psychology to its component parts, it is easier to obtain a clear picture of this special cohort of patients. Considering the increase in number of geriatric edentulous patients, this knowledge will help the dentist serve the geriatric population better. Background: The role of psychology and personality in complete denture treatment is well documented. The geriatric patient who needs complete dentures has a psychological aspect that needs consideration. Although signicant, these aspects may sometimes be ignored or considered irrelevant. Materials and methods: A review of relevant literature was carried out to obtain data on the psychology and personality of geriatric, complete denture patients and their behavioural changes. The obtained data was ltered and condensed to provide a short but comprehensive look at the geriatric edentulous patients psychology. Conclusion: When handling geriatric edentulous patients, the dentist must be condent of addressing and managing the psychology of these patients. A thorough understanding of the geriatric mental state thus becomes important and signicant for the clinician. Keywords: geriatric patients, geriatric psychology, complete denture patients. Accepted 28 November 2010

Introduction
Today, the geriatric population is on the rise because of an increase in the quality and availability of medical facilities, introduction of new drugs and disease control combined with better nutrition and improved hygiene. This implies that a greater number of geriatric patients will seek dental care including complete prosthodontic care. The success of complete dentures is related to technical procedures, functional factors, aesthetics, biological determinants and psychological factors. The psychological factors include preparedness of the patient, attitude towards dentures, relation and attitude towards dentist, ability and intelligence to learn use of dentures and the patients personality.1 The relationship between psychology of the patient, personality, the dentist patient interaction and denture treatment is well recognised.17 We have tended to stereotype the aged as senile, nancially and emotionally dependent, useless and ill. Their wisdom, experience and accrued

expertise are constantly being misused, wasted or ignored.8 For the population over 65 years of age, Birren identies ve sources of frustration that are agerelated: (i) an age status system that idealises youth, (ii) pressures of time and money that leads us to a restriction of former interests, (iii) physiological changes that demand or usurp attention, (iv) technological changes that increasingly outdate the skills of ageing persons and (v) with age, individuals become more locked in, being less able to move out of a frustrating situation.9 The earlier the signs of frustration are detected and correlated to the source(s) the better are the chances of understanding the patients psychological make-up and delivering better care. What to expect? Jamieson10 wrote that tting the personality of the aged patient is often more difcult than tting the denture to the mouth. The geriatric patient seeking
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complete denture treatment is classied in many ways by various researchers. The numerous classications available in literature highlight the depth of study of the psychology of the geriatric denture patient and an effort to understand it to in turn provide better care for the geriatric denture patient. It also reects the variety and wide variation that is observed in the mental make-up of the geriatric patient. Ettinger and Beck11 divided geriatric patients functionally into (i) functionally independent elderly: live in the community unassisted (ii) frail elderly: have lost some of their independence, but still live in the community with the help of support services and (iii) functionally dependent elderly: unable to live independently in the community. Years ago, House classied patients into four types: philosophical mind, exacting mind, hysterical mind and indifferent mind.12 Patients with an exacting mind, hysterical mind or indifferent mind were believed to exhibit less than ideal adaptability to edentulism and denture use. More recently, Gamer et al.13 suggested a re-evaluation of the Houses classication because of the following reasons (i) the classication uses antiquated terminology (ii) it considers the patient in isolation. The new system classies the patients into ideal, submitter, reluctant, indifferent or resistant. This system, in addition to the patient, takes into consideration the dentist and the interaction between the dentist and the patient. Winkler8 also mentioned the following categories of patients. 1. The hardy elderly: these are individuals who are well-preserved physically and psychologically, are active in their professional and social lives and quickly adapt to their age changes. 2. The senile aged syndrome: these are individuals who are disadvantaged emotionally and physically and may be described as handicapped, chronically ill, disabled, inrm and truly aged. They cannot handle daily stresses and are susceptible to disease. 3. The satised old denture wearer: these patients are satised with their old dentures in spite of severe problems. They have learned to live with them and are happy with them. 4. The geriatric patient who does not want dentures: an elderly person who has been without teeth for many years and has no desire for complete dentures and lacks motivation. The last two categories of patients lack motivation and have a poor prognosis if forced into undergoing treatment.

The ideal geriatric denture patient OShea et al.14 characterised the ideal dental patient as compliant, sophisticated and responsive. Winkler15 described four traits that characterise the ideal patients response: realises the need for the prosthetic treatment, wants the dentures, accepts the dentures and attempts to learn to use the dentures. It is evident from the various classications1315 that a so-called ideal psychological prole, though rare, is often desired by most dentists as it provides the greatest chance of success. Strictly speaking, the denition of the term ideal may be relative, but it does provide a standard to refer to. Understanding the aged No matter how the patients are classied, the characteristic they all have in common is tooth loss. Tooth loss brings about considerable changes in the psychology of patients. Psychological assessment of the patient becomes essential because the success of the treatment depends on the expectations and the self-concept of the patient.16 According to a study conducted by J. Fiske et al., 17 the emotional effects related to tooth loss ran parallel with the ve stages of bereavement, i.e. denial, anger, depression, bargaining and acceptance. In patients who had failed to reach the nal stage of bereavement, the following emotional responses were noted: lack of acceptance; diminished self-condence; difculty in adjusting to a change in appearance and self-image; treating the subject of tooth loss as a taboo topic; secrecy or an attempt to hide the edentulousness; prosthodontic privacy or a fear of removing the dentures; behaviour change; feeling of having aged prematurely; lack of preparation to face the tooth loss. Handy proposed that, like losing a body part, tooth loss too can affect the personality or psyche and that it may be a response to the extractions and/or denture construction and not an inherent aw in the psychological make-up of the patient.17 Tooth loss and its acceptance are one of the major factors determining the psychology of geriatric complete denture patients. Another important factor is the inherent differences between young and old patients. Older patients are behaviourally different when compared to younger patients. They are more sceptical, demanding and at times quite a challenge to handle.

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Heartwell18 states that aged patients rarely expect to see with an articial eye or to have natural use of an articial hand or leg, yet they frequently expect articial teeth to duplicate natural teeth in form and function. Many of them have a tendency to exaggerate their problems, and such situations require the dentist to have a lot of patience and understanding. Winkler8 states that geriatric patients remember all the claims made by the dentist and if the prosthesis is not exactly as it was described, they will invariably complain. Elderly people develop xed habits and ideas and do not adapt readily to change in their mode of life. They tend to endure increasing physical discomfort rather than to make an effort to see a doctor for the early treatment of an ailment that may become serious.10 At the other end of the spectrum, Winkler8 and Iacopino19 separately mention the routine of the geriatric patient who visits a sympathetic or comforting dentist for reassurance. They also believe that working briskly and being overly efcient is construed as indifference by the geriatric patient. Most geriatric patients come from an age where speaking up is considered ungrateful and critical, and an expression of emotions is considered as a sign of poor self-control. Most patients are not familiar with the concept of preventive treatment, being used to curative treatment only. Lower educational achievement is also a factor that inhibits effective communication. Patients attitudes are inuenced by prior dental experience, the importance of dentistry (from the patients point of view) and dental awareness.20 Researchers have shown that older people take more time to process new information, and they need a slower pace of instruction and more time to process new information. Another deterrent to successful communication with older patients is the normal, age-related decline in sensory processes. As patients get older, they cannot see, hear, touch, taste or smell as well as they did when they were young. Depressed patients and those suffering from hypochondria focus on the body; thus, they will be more likely to respond to, or report as, pain even minor non-pain sensations such as vibration.16 In explaining the psychology of the dentally phobic geriatric patient, Epstein20 states that the oral cavity is often experienced by the patient as the point wherein the dentist trespasses into the patients body. Inuence of personality A correlation between the personality of a patient and the denture acceptance exists.1,7 Ozdemir

et al.6 compared the denture satisfaction in type A and type B personalities. Type A personalities lead high stress lives, whereas type B personalities are relaxed and stress free. Type AB personalities are located between these two extreme groups. Patients with personality Type A exhibited the lowest levels of satisfaction with their dentures with regard to aesthetics, speaking ability and masticatory function. Patient behaviour towards the dentist Lefer et al.,3 commenting on the dynamics of the dentist patient interaction, predict one of two patient behaviour patterns. The patient may have the expectation that the dentist will take care of him and be gentle if he defers all decisions to the dentist. At the other end of the spectrum, a patient may feel that submission to an authority gure is a sign of weakness. As a result, he may resist anyone who displays authority. In a study conducted on the dentist patient interaction, Hirsch et al.21 found that patients treated by high authoritarian dentists were less satised than those treated by low authoritarian dentists. The geriatric patients response to form and function of dentures Pan et al.22 when evaluating sex-related differences in patient behaviour to complete dentures found that elderly females are less satised with conventional dentures than elderly males with regard to aesthetics and ability to chew. This result is partly supported by a previous study by Langer et al.2 who found that more women complained about the appearance of their dentures, while more men had objections regarding mastication. Waliszewski et al.23 evaluated preference of tooth arrangement (aesthetics) among edentulous patients using three types of set-ups, i.e. natural, supernormal and denture look. The natural look was a standard tooth arrangement, while the supernormal and denture look were with larger and smaller moulds of teeth, respectively. The results showed that a natural look was chosen by 55% of the patients, whereas the other 45% chose set-ups that were marked deviations from the anatomical averages (either supernormal or denture look). Adaptation to dentures The acceptance of dentures is usually unrelated to the technical quality of the prosthesis2,17,19,24,25 All

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or most of the above factors contribute to the patients acceptance of the dentures. According to Anderson,26 the popular belief that patients adapt better to duplicated dentures than new ones is unfounded. In comparing the better technique for denture construction, Ellis et al. 27 made the following observations: (i) after delivery, the edentulous patients who received complete dentures using either conventional or duplication techniques showed similar improvements in terms of overall patient satisfaction and oral health-related quality of life and (ii) Patients reported satisfaction with their dentures and the impact dentures had on their quality of life might not be useful measures for determining the most appropriate technique for providing new dentures. A study by Fiske et al.28 investigated the role of a self-help group in helping denture wearers with long-standing problems. During the course of the investigation, the following observations were made: sharing problems helped people to accept and cope with them. Patients included foods they previously did not attempt to eat, and they communicated their problems better than before. It was also found that the responsibility for successful denture wearing was placed totally with the dentist, and most patients thought that there was nothing they could do to contribute to successful denture wearing. The patients suggested that the dentists listen more and explain everything including potential denture problems.

Conclusion
Knowledge of patient psychology helps us in understanding the mental status of a patient who has suffered tooth loss and is in need of treatment. Knowing what to expect when treating a geriatric edentulous patient puts the dentist at a distinct advantage as a treatment plan can be formulated accordingly. This will facilitate an improved approach towards the patient and will help in more appropriate management of the patient, both psychologically and prosthodontically.

References
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Correspondence to: Dr Mysore Ashwin Raghunandan, Goa Dental College and Hospital Prosthodontics, Rajiv Gandhi Medical Complex, Bambolim, Goa 403202, India. Tel.: 9890749016 Fax: 0091-0832-2459816 E-mail: ash_win1@rediffmail.com

2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e23e27